Happy Holidays!

Quick time out to say happy whatever-if-any-winter-holiday-you-celebrate.  And thanks to the donors who allow the kids in hospitals over the holiday (well, at least in mine) to be spoiled rotten in return for having to be there.

"My doctor didn't DO anything!"

Parents tend to expect the "miracles of modern medicine."  When they take their sick little one to the doctor, they expect that doctor to do tests, instantly discover exactly what is wrong with the child, and prescribe curative treatment.  If that doesn't happen, they think their doctor "didn't do anything."

When I see a sick child, I start by taking a history.  Much of the time I spent learning what questions to ask seems wasted, though, because no one wants to give me any detailed answers.  I frequently get such vague, uncommunicative answers that I wonder if the parents actually live with the child.  They certainly don't seem to know much about the child.  I was trained to use the answers to my initial questions to guide further questions.  This is often met with impatience, as parents don't seem to understand why I need this information.

After I have given up on prying any more information out of the parents, I examine the child.  Small infants are pretty easy; the worst thing they can do is puncture my eardrums by screaming while I try to listen to their lungs.  Toddlers don't understand what I am doing, and I don't blame them for resisting; but the little shits are strong, and often leave bruises.  The trauma of a toddler exam-to both the child and the doctor-can be minimized if a parent will help.  Too often the parent is texting and ignoring the kid.  Even if they aren't, many don't want to hold the kid still enough.  While I don't mind being hit or kicked by toddlers, I DO mind that behavior from supposedly normal school-aged kids.  I understand that a medical examination is unpleasant and scary.  But school-aged kids are old enough to understand that they need to hold still for a few minutes.  I have seen kids who are never made to obey at all.  I have seen kids who hit and kick their own parents-who just sit there and take it.  However, I get as thorough an exam as I can.

Once I have done that, I put the history and physical findings together to figure out what is most likely going on.  I may need to do tests to confirm my diagnosis; I may not.  I don't do tests that I don't think are necessary, because I find it unethical.

After I have examined the child, and decided if I need tests, I can recommend the best course of treatment.  Believe it or not, sometimes the best thing to do is rest and fluids.  At home. This is when it gets hairy.  You see, all I did is talk to the parents and poke the kid, then gave the same advice they already got from their grandmother.  No zillion-dollar tests to pinpoint the EXACT problem.  No unpronounceable medications that were in TV ads.  No CURE.  Why the hell would I just tell them the kid has a cold?  How lazy can I get?  They will go somewhere else, and keep doing so until they find a doctor who will DO something.

I spent a lot of time in training to learn when to do what.  If the kid has a viral upper respiratory infection-a cold-there is no need to know which virus it is.  It's all treated the same.  By treating the symptoms.  No antibiotics.  If a baby spits up, try smaller feedings, not a cat scan and drugs.  Have some sense.  Please.  You can even get it without a prescription.

Patient satisfaction

I want to preface my post by saying that I snark and bitch about a lot of things.  It's the whole reason I created my blog.  But most of those things are relatively minor.  They don't diminish my love of being a doctor.  What I am about to talk about does diminish that love.  It makes me wonder if I am in the wrong career.

I spent years in medical school, residency and fellowship to learn how to diagnose and treat patients.  I put my adult life on hold while I did this, and went hundreds of thousands of dollars in debt for school.  After training, I spend hours in continuing medical education so I can keep up on the latest science-based treatments.

However, I seem to have wasted my time.  You see, now insurances have tied reimbursements to patient satisfaction.  If the patient satisfaction scores are good, the hospital gets paid.  If they aren't, no pay.  I want my patients to be satisfied that they got good medical care with appropriate communication.  But that isn't what makes high satisfaction scores.  That comes when families get what they want-regardless of what they need.  The parents of a child with functional abdominal pain (meaning belly pain without any identifiable cause) will INSIST he needs a CT scan.  Never mind that he has had 3 normal ones in the last 2 months.  Never mind that CT scans have a crapton of radiation, and the kid is being put at increased risk of cancer.  And their grandkids will have 3 heads.
The family of a kid with heartburn doesn't want to hear that maybe the kid should eat less fried and spicy food, and not eat at bedtime.  No, they want an endoscopy to find the problem.  Not only does the procedure itself carry inherent risk, but it usually requires sedation.  That only adds risk.
Parents Google their kids' symptoms, decide what they think the kid has, and what tests and treatments they need.  We, as medical professionals, are supposed to provide whatever is demanded.  When we don't, people complain.  After all, they are paying us to do whatever; we should do whatever they want.

I want to make myself very clear.  You are NOT paying me to just order whatever you tell me to.  You are paying me to assess your child, decide what diagnostic tests are appropriate, interpret them, and come up with a treatment plan.  If what you really want is to diagnose and treat your own child with help from the internet, write your own damn orders.  I have better things to do than take dictation.

Public Service Announcement

This is for the parents who allow their kids to be brats at the hospital or doctor's office.  Yes, I know that pediatricians and their nurses are expected to use "child-friendly" language at all times.  However, if your demonspawn bites someone, don't be shocked if they react with four-letter words.  If you don't want to hear your kid referred to as a little shit, don't let him be one.

Vaccine Package inserts

I am pro-vaccine.  I just wanna get that out there.  That said, I have seen a lot of anti-vaccine activists making arguments and supporting themselves by citing the package insert-somewhat erroneously.

For starters, those inserts are not like food labels; that is, they are not meant to educate the general public.  For one, they are geared toward medical professionals.  They are not written in lay language.  Two, they are mostly a legal document.  They have to tell the ingredients.  When it comes to side effects, that's where the confusion starts.  You see, during a clinical trial, any symptom that develops is assumed to be from the experimental drug.  If a test subject reports that he farted, then "flatulence" will be listed as a side effect.  It does not matter if the symptom is actually related to the drug.  If I were in a trial right now, and was asked if I had pain, I would have to tell them my foot hurts.  They would put "foot pain" as a side effect of the drug-even though I broke my damn foot last week, and THAT is why it hurts.

Because they are not written in lay language, a lot of people misinterpret.  When the insert says, correctly, that a small number of patients don't respond, people take that to mean that the vaccine never works and is useless.  While we're on that subject, many of them will say something like "studies have proven that this vaccine induces an immune response.  No study has proven that there is a decrease in disease incidence with this vaccine."  Again, that is a lawyer-mandated CYA comment.  Of course there isn't such a study.  You'd have to get a big group of  people, randomly give half of them the vaccine and the other half a dummy shot, then (after giving the immune system time to respond) expose them all to the active disease and see which group gets sick more.  That violates human research ethics in so many ways.  Intentionally give people disease?  Google "Tuskeegee Syphilis Study" and read about it.

I get really mad when people go on about how much better immunity is when induced by "a simple childhood illness."  Ummm, the point of the immunity is NOT TO GET THE ILLNESS.  It isn't always sneeze twice and go on with life.  In the interest of full disclosure I will say that I do not now, nor ever have in my career, make ONE SINGLE PENNY from vaccines.  But I want these illnesses eliminated.  I only see sick kids; I wish my whole specialty would become unnecessary because all kids were healthy.

I attended the most appalling committee meeting today.  The meeting discussed using an electronic tool to track "quality measures" of a doctor's performance.  The members of the committee had to decide what to measure (mostly bullshit paperwork), how to measure it, and how to discipline docs who don't meet expectations.  It was bad enough that very few of the measures had any real meaning.  What appalled me is that the committee consisted mostly of administrators and nurses-only 2 docs.  It wasn't that my colleagues didn't come; most of them weren't invited (I don't know how I was; I'm not usually on that committee).

Patience, grasshopper.

Yesterday I admitted a kid with pneumonia.  He looked pretty miserable, with a  high fever, working to breathe and needing oxygen by face mask.  I started him on treatment and told his parents it could take a few days.
Today, when I made rounds, his mother accosted me anxiously.  She wanted me to "run more tests" since, according to her, he wasn't getting any better (in less than 24 hours!).

When I went in to look at him, his fever was much lower.  He was breathing more easily.  He needed less oxygen, and was even hungry.  Needless to say, I did NOT order more tests.

I don't treat to order.

I am SO annoyed by parents who think they know everything.  We occasionally get parents who decide, at home, what treatment their child needs.  Since that treatment has to be provided by a doctor, they bring the kid in.  Not to have the doc evaluate the kid and recommend a treatment course.  Just to have the doc provide the treatment that the parents already decided they want.  The parents get so pissed when I insist on examining the child and offering only appropriate treatments.  Medicine has gotten so commercialized that people think they can just order whatever treatment they want.

Public Service Announcement

Parents of the world:  taking your child to the emergency room (or urgent care, or primary doctor) for a viral infection does not magically cure that infection.  Your child will likely still have symptoms, including fever, for several days.  There is no need to bring your child to the ER every day until they admit you.  Let your kid rest, give plenty of liquids and Tylenol as instructed.  Thanks.